2018 Section 6 - Laryngology, Voice Disorders, and Bronchoesophalogy

Otolaryngology–Head and Neck Surgery 00(0)

gastroesophageal reflux disease (GERD) or laryngopharyngeal reflux (LPR), without visualization of the larynx. (3) Clinicians should not routinely prescribe corticosteroids for patients with dysphonia prior to visualization of the larynx. The policy level for the following recommendation about laryngoscopy at any time was an option : (1) Clinicians may per- form diagnostic laryngoscopy at any time in a patient with dysphonia. Disclaimer. This clinical practice guideline is not intended as an exhaustive source of guidance for managing dyspho- nia (hoarseness). Rather, it is designed to assist clinicians by providing an evidence-based framework for decision-making strategies. The guideline is not intended to replace clini- cal judgment or establish a protocol for all individuals with this condition, and it may not provide the only appropriate approach to diagnosing and managing this problem. Differences from Prior Guideline (1) Incorporation of new evidence profiles to include the role of patient preferences, confidence in the evidence, differences of opinion, quality improvement opportuni- ties, and any exclusion to which the action statement does not apply (2) Inclusion of 3 new guidelines, 16 new systematic reviews, and 4 new randomized controlled trials (3) Inclusion of a consumer advocate on the guideline update group (4) Changes to 9 KASs from the original guideline (5) New KAS 3 (escalation of care) and KAS 13 (outcomes) (6) Addition of an algorithm outlining KASs for patients with dysphonia Keywords dysphonia, hoarseness, voice change, voice disturbance, voice disorders, laryngitis, voice, guidelines Received May 26, 2017; revised August 14, 2017; accepted December 8, 2017. D ysphonia (impaired voice production) is a very com- mon complaint affecting nearly one-third of the popu- lation at some point in its life. 1-3 The term dysphonia is often used interchangeably with hoarseness ; however, this

terminology is imprecise, as hoarseness is a symptom of altered voice quality reported by patients, while dysphonia characterizes impaired voice production as recognized by a clinician. 4 Dysphonia can affect patients of all ages and sex but has an increased prevalence in teachers, older adults, and other per- sons with significant vocal demands. 5-8 In fact, voice prob- lems affect 1 in 13 adults annually. 9 While patients report a significant impairment of the voice, a relative minority seeks medical care for the voice problem. 9-11 Dysphonia is respon- sible for frequent health care visits and several billion dollars in lost productivity annually from work absenteeism. 12 Dysphonia is often caused by benign or self-limited condi- tions, but it may also be the presenting symptom of a more serious or progressive condition requiring prompt diagnosis and management. This clinical practice guideline (CPG) is as an update of, and replacement for, a guideline published in 2009 by the American Academy of Otolaryngology—Head and Neck Surgery Foundation (AAO-HNSF). 13 An update was necessitated by new primary studies and systematic reviews that suggest a need for modifying clinically important recommendations, as well as by the elapsed time since the original guideline. Changes in content and methodology from the prior guideline include • • Incorporation of new evidence profiles to include the role of patient preferences, confidence in the evi- dence, differences of opinion, and quality improve- ment opportunities • • Inclusion of 3 new guidelines, 16 new systematic reviews, and 4 new randomized controlled trials (RCTs) • • Inclusion of a consumer advocate on the guideline update group (GUG) • • Changes to 9 of the key action statements (KAS) from the original guideline • • New KAS 3 (escalation of care) and KAS 13 (out- comes) • • Addition of an algorithm outlining KASs for patients with dysphonia The working definitions found in Table 1 were developed by the guideline panel, and they assume that dysphonia affects people differently. The target population for this guideline includes all individuals presenting with dysphonia, regardless of age. The guideline is intended for all clinicians who diag- nose and treat patients with dysphonia, and it applies to any

1 Wayne State University, Detroit, Michigan, USA; 2 University ofWisconsin, Madison,Wisconsin, USA; 3 Virginia Mason Medical Center, Seattle,Washington, USA; 4 Private practice, Lake Mary, Florida, USA; 5 Oklahoma State University, Oklahoma City, Oklahoma, USA; 6 Ohio State University, Columbus, Ohio, USA; 7 Henry Ford Health Systems, Detroit, Michigan, USA; 8 Indiana University, Bloomington, Indiana, USA; 9 National Spasmodic Dysphonia Association, Itasca, Illinois, USA 10 University of Pittsburgh Medical, Pittsburgh, Pennsylvania, USA; 11 University of Utah School of Medicine, Salt Lake City, Utah, USA; 12 Private practice, Sherwood,Arkansas, USA; 13 Icahn School of Medicine at Mt Sinai, NewYork, NewYork, USA; 14 Department of Research and Quality,American Academy of Otolaryngology—Head and Neck Surgery Foundation,Alexandria,Virginia, USA.

Corresponding Author: Robert J. Stachler, MD, Stachler ENT, 33200West 14 Mile Rd, Suite 240,West Bloomfield, MI 48322, USA. Email: robstachler@comcast.net

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